New Patient Form

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APPLICATION GUIDELINES & OFFICE POLICIES

Thank you for considering Whole Health Center Houston as your partner in healing and healthy living! Please submit this form to begin your journey of healing at Whole Health Houston. Feel free to call if you have any questions or if you would like clarification.


INSURANCE POLICY

Because of the nature and scope of our practice, we are a Direct-Pay practice and we DO NOT accept insurance. As a courtesy, we will provide you with a statement which is necessary for you to file an insurance claim with your provider.

Acknowledgment of Insurance Policy*


Medicare and Medicaid Opt-Out

We have chosen to opt-out of the Medicare/Medicaid system, and therefore services provided by Whole Health Center Houston are not eligible to be covered by Medicare or Medicaid. If you are covered by Medicare or Medicaid, we will require that you sign the federally-mandated patient-doctor opt-out contract.

Acknowledgment of Medicare and Medicaid Opt-Out*


SELECT YOUR PACKAGE*

If you haven’t already done so, please take a few moments to review our Package offerings and discounts for new patients here. Then, select the appropriate Package below:


OUR PROVIDERS

Our holistic team is experienced, knowledgeable and ready to guide you toward Whole Health.  All of our providers practice with the same holistic approach and philosophy, and consult one another continually to ensure our patients are getting the highest level of care. Our policy is to schedule you with the first available provider. You may, however, indicate your preference below and we will try to accommodate you. 

Provider Preference (if any)

Erin Gussler, R.D.N. L.D. C.L.T. (Nutrition Package only)

MEDICAL HISTORY

The information we ask for in this form is to help us prepare for your visit and hopefully exceed your expectations. Please fill in this form as completely as possible.

Member Personal Information

Parent or Guardian

Primary person for discussing child's health information?

Contact Information & Communications


Member Portal

To gain online access to your medical records and secure communications, please create a username and password password.

Your username must be at least 4 characters long

Your password must be at least 8 characters long and include at least one number or special character.

Alternate Contact Person

Used in case of emergency or inability to contact primary person.

How did you hear about us?*

Tell us more about yourself

Health History

This health information is used only for our medical purposes and will not be shared with any third-parties without your permission. We do NOT use health status to determine fees or deny membership.

Current Medications

Please include any and all medications you are taking regularly or "as needed."


If you are taking any of the below medications, please review our MEDICATION POLICIES to make sure Whole Health Center Houston is right for you. 
  • Amphetamines (Ritalin, Adderall, Phentermine, etc.)
  • Opiates (Morphine, Hydrocodone, Lortab, Codeine, etc.)
  • Benzodiazepines (Lorazepam, Valium, Xanax, etc.)
  • Sleeping Medications (Ambien, Lunesta, etc.)

Current Vitamins, Herbs, or Supplements

Please include any and all vitamins, herbs, or supplements you currently use.

Medical Summary*

Medical Diagnoses

List all medical conditions with which you have been formaly diagnosed, and the approximate month/year of your diagnosis.

Your Goals and Questions

We want to fulfill your expectations, so please take a moment to tell us your primary goal and questions for your visit.

Please tell us your MAJOR GOALS for your first visit.

What would you like to accomplish before leaving our office?

Please tell us what QUESTIONS you would like answered by the doctor during your first visit.

Note: if you have any questions about our process for applications, or any other general question you would like answered BEFORE your first visit, then please call our office at 713-840-9355 or send us an email at GetWell@wholehealthhouston.com.

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